Contraceptive patch

The oestrogen/progestogen patch contains hormones that are absorbed transdermally. The patch is 93% to 99% effective for pregnancy prevention (typical to perfect use) (1)

• EVRA (R) is a contraceptive patch that delivers ethinylestradiol 20 mcg and norelgestromin 150 mcg per 24 hour period. The contraceptive patch is applied weekly for 3 consecutive weeks commencing on the first day of menstruation, followed by one patch-free week
• evidence from trials of the patch against combined oral contraceptives found greater compliance with the contraceptive patch when assessed by daily patient diaries - however it is not known, if, or to what extent, the greater compliance for use of the contraceptive patch will lead to a reduction in pregnancy rates in general use
• one Cochrane review noted that, compared with combined hormonal pill users, women using the norelgestromin-containing patch experienced more breast discomfort, dysmenorrhoea, nausea, and vomiting in comparison with combined oral contraceptives (2)
• the efficacy of the EVRA patch may be decreased in women who weigh more than 90 kg and so additional precautions or an alternative method should be advised for women in this category (3)

Criteria for exclusion (4)

• as per combined oral contraceptive pill
• Interacting medicines (other than enzyme inducers) – see current British National Formulary (BNF) www.bnf.orgor individual product SPC http://www.medicines.org.uk

Cautions including any relevant action to be taken (4)

• If the individual is less than 16 years of age an assessment based on Fraser guidelines must be made and documented
• If the individual is less than 13 years of age the healthcare professional should speak to local safeguarding lead and follow the local safeguarding policy.
• Discuss with appropriate medical/independent non-medical prescriber any medical condition or medication of which the healthcare professional is unsure or uncertain.
• Individuals taking lamotrigine should be advised that CHC may interact with lamotrigine; this could result in reduced seizure control or lamotrigine toxicity.
• Offer Long Acting Reversible Contraception (LARC) to all individuals in particular those with medical conditions for whom pregnancy presents an unacceptable risk and those on a pregnancy prevention plan
• If an individual is known to be taking a medication which is known to be harmful to pregnancy a highly effective form of contraception is recommended. Highly effective methods include the LARC methods: IUD, IUS and implant. If a LARC method is unacceptable/unsuitable and a CHC is chosen then an additional barrier method of contraception is advised. See FSRH advice

Dose and frequency of administration (4):

• Each patch releases 33.9 mcg ethinylestradiol and 203mcg norelgestromin per 24 hours over a seven day period.
• FSRH guidance states that CHC can either be used following a standard or tailored regime.
• Individuals should be given information about both standard and tailored CHC regimens to broaden contraceptive choice.

Regimes

• The patch can either be used as a standard regime or in a tailored regime depending on the choice of the individual.
• The regimes which can be advised are detailed below:

• A single patch applied at the same time each week for seven days starting on day 1-5 of the menstrual cycle with no need for additional protection.
• The patch can be started at any time after day five if it is reasonably certain that the individual is not pregnant. Additional contraception is then required for seven days after the patch is applied
• When starting or restarting the CHC as quick start after levonorgestrel emergency contraception, additional contraception is required for 7 days and a pregnancy test should be performed 21 days after the last unprotected sexual intercourse.
• In line with FSRH guidance individuals using hormonal contraception should delay restarting their regular hormonal contraception for 5 days following ulipristal acetate use. Avoidance of pregnancy risk (i.e. use of condoms or abstain from intercourse) should be advised until fully effective.
• For guidance on changing from one contraceptive method to another, and when to start after an abortion and postpartum, refer to the FSRH guidance

The summary of product characteristics must be consulted before prescribing this drug.

References:

1. Hatcher R. Contraceptive technology. 21st ed. New York: Ardent Media; 2018.
2. Lopez LM, Grimes DA, Gallo MF, et al. Skin patch and vaginal ring versus combined oral contraceptives for contraception. Cochrane Database Syst Rev. 2013 Apr 30;(4):CD003552
3. The Faculty of Sexual & Reproductive Healthcare (FSRH) of the Royal College of Obstetricians & Gynaecologists. Clinical guidance: combined hormonal contraception. Nov 2020 [internet publication].
4. Patient Group Direction (PGD) (NHS Specialist Pharmacy Service). Supply of combined hormonal contraceptive transdermal patch.